Introduction
Atopic dermatitis (AD) is a chronic
inflammatory skin disease
affecting the pediatric and adult population with a lifetime prevalence
of up to 20%1. It is characterized by recurrent itchy
eczematous lesions, papulation, and lichenification, with high
heterogeneity of clinical manifestations and diffuse dry skin as an
expression of skin barrier dysfunction1.
Aside from the cutaneous signs and symptoms of AD, several atopic and
non-atopic comorbidities can occur in AD patients1–3.
Not surprisingly, the severe, persistent, and debilitating itch, typical
of AD, causes sleep deprivation, anxiety and depression, and reduced
quality of life and productivity2,3.
Sleep disturbances are one of the most relevant non-atopic
comorbidities, reported by 33 to 87.1% of adults with
AD4,5, a much higher percentage than the prevalence in
the general population (7–48%)6. AD patients report
lower sleep quality and more insomnia symptoms, experiencing difficulty
in falling asleep, increased frequency and duration of nocturnal
awakenings, and shorter sleep duration, which can lead to excessive
daytime sleepiness, fatigue, and dysfunction3–9.
Overall, sleep disorders significantly impact the general health and
quality of life of AD patients10, impairing work and
home functioning and interpersonal relationships6 and
playing a critical role in the development of
cardiovascular11, metabolic12, and
psychiatric diseases13.
Psychological disorders represent another common comorbidity in the AD
population. Patients with AD often develop psychosocial distress with
high rates of mental disorders, such as depression and
anxiety14–18. However, relatively little is known
about AD and self-perceived stress in adults19–21.
Stress could aggravate and trigger skin diseases22.
Likewise, some dermatoses are a source of stress and impair quality of
life19.
Despite their importance, sleep and psychological stress in AD were
investigated by a few studies. Moreover, the literature in this field is
limited to using simple dichotomous or Likert-type questions when
comparing AD and healthy subjects5,20,21,23. Other
studies on sleep in AD have even referred to single items taken from
mood or quality of life questionnaires, neglecting the
multidimensionality of sleep5,6,23. Therefore, the
first aim of our study was to use a set of validated questionnaires to
investigate sleep quality, insomnia, depression, anxiety, and perceived
stress in AD patients through a case-control study. We hypothesize that
more severe sleep disturbances, insomnia, depression, anxiety, and
perceived stress may be observed in adults with AD than in the healthy
population.
Although the relationship between AD, sleep, and psychological disorders
is widely recognized, it is unclear how AD is associated with sleep and
mental health problems. Investigations on the association between AD
severity and sleep disorders showed conflicting
results5. In most studies, sleep disturbances and
quality appeared to worsen with AD severity; in others, only weak
correlations or no significant correlation have been
observed3–5,9. Similarly, some studies reported that
increasing AD severity is associated with higher rates of depression,
alexithymia, suicidal ideation, and anxiety15,16,18,24, but others showed that AD adults were
more likely to develop depression and anxiety regardless of atopic
eczema severity14. In contrast, most studies did not
correlate psychological symptoms with AD severity18.
To our knowledge, few studies have investigated the relationship between
AD severity and self-perceived stress19,20.
Over time, the chronic nature of AD leads patients to face several
difficulties that depend not only on the condition severity but
especially on the personal perception of the
disorder25. The perception of the disease is strongly
influenced by the individual’s experience and interpretation of the
disorder26.
To date, the severity-dependent relationship between AD symptoms and
sleep and psychological disturbances has been studied mainly through
objective tools widely used in clinical trials. However, the importance
of patients’ disease perception versus objective measures should be
considered in clinical and research settings25,26.
In this regard, the second objective of our study was to investigate the
severity-dependent relationship between AD symptoms and sleep quality,
insomnia, depression, anxiety, and perceived stress by differentiating
clinical-oriented measures from patient-oriented subjective measures of
the disease.